I had high expectations for Janet Radcliffe Richards’ new book, and the author meets these expectations by articulating cogent, practical proposals to solving one of the greatest problems facing contemporary bioethics – the shortage of healthy organs for transplant. Unfortunately, these ideas are buried in an otherwise bewildering maze featuring a discussion of vague cultural pressures against organ donation, largely irrelevant concerns about policies regarding organs from living donors, and questions about the current medical conception of death.

II. Outline

The book is divided into five chapters. The first serves as an introduction to the problem of the scarcity of organs for transplant. Here, Radcliffe Richards argues that organ donation is prima facie morally desirable as it saves lives. She succeeds outlining many of the objections donors have towards donating organs in this and the last chapter. Roughly, scarcity is exacerbated by two factors – (1) prior to organ donation many cultures adopted practices for dealing with the dead and have largely failed to revise these practices, and (2) many patients fear that medical professionals might unduly harvest their organs. Regrettably, Radcliffe Richards fails to offer clear approaches for solving these problems

The second chapter concerns procurement of organs from the living. This chapter gets bogged down in questions about the appropriateness of purchasing organs, and the entire discussion is out of place as, in most cases, organs procured from the living, such as kidneys, do not save lives; they merely increase quality of life. The third chapter consists of a rather odd meta-ethical inquiry into the ends of bioethics, but as with the second chapter, this is largely irrelevant to the problem of scarcity.

The fourth chapter, concerning procurement of organs from the dead, is the strongest chapter in the book, although much of this chapter is marred by the permissive stance she took in the second chapter. She argues that organs should be seen as property, and thus willed by their owner, rather than be subject to the whims of the donor’s family. However, she also argues that one should be able to directly donate organs, perhaps for some financial reward, having previously argued that we should explore allowing selling of organs. Finally, she discusses a policy that organ donors be given priority on the transplant waiting list.

In the final chapter, Radcliffe Richards ties willful scarcity regarding organs to questions regarding whether we have any shared, coherent medical account of death. Potentials donors fear both ignorance and nefarious intent from their medical professionals, she argues.

III. Review

Radcliffe Richards successfully identifies many sources that have contributed to the increased scarcity of organs, and proposes several interesting approaches to increase organ donation. However, these proposals are light on specifics and heavy-handed, largely ignoring questions of the morality of refraining from being an organ donor.

All else being equal, to refuse to be an organ donor is to consent to letting other people die when you could have saved their lives at no cost. This is morally repugnant. Unfortunately, Radcliffe Richards spends little time attempting to defend the cultural practices that get in the way of organ donation, and without such a defense, to adhere to these practices at the cost of other lives is vicious. Her discussion of the fears that prevent patients from donating organs is relatively compelling, but she fails to propose an adequate policy to combat these concerns. One such plausible policy would be to adopt harsh penalties for hospitals and medical professionals who are caught harvesting organs when they should be acting to save lives. There are many benefits to setting up a universal, patient-identity blind medical database; one such benefit is that that statisticians looking to improve healthcare can see which doctors and hospitals harvest the most organs, and investigate how to replicate their success. Coupled with electronic records and digital surveillance of medical rooms, investigators could easily determine whether increased organ harvest is a matter of skill, luck, or murder by doctor.

The most engaging discussion in the book is Radcliffe Richard’s discussion on reciprocity (188-193), in which she discusses a policy that would place non-donors at the ends of the transplant waiting list, providing everyone with a strong incentive to be an organ donor. As engaging an idea as this is, I found the discussion deficient in two ways. First, this policy was discussed largely without concern for its application. Because the policy would levy harsh penalties against non-donors, it should only be adopted with an opt-out policy, such that the individual has to act to lose their priority, rather than act to gain it. Countries with opt-out policies already have a larger percentage of their population as organ donors, so the commonsense opt-out policy alone would successfully increase the number of organs available to save lives.

Second, to freely choose not to donate one’s organs is usually an indefensible choice; it risks the lives of others for no gain. As such, it strikes me that those who freely choose to opt-out of organ donation not only should be moved to the end of the transplant list, but perhaps they should be booted from the list entirely. At present, many people lose their position on the list because they freely choose to engage in risky behavior such as smoking. It strikes me that these people are, all else being equal, more worthy of a donated organ than non-donors; thus perhaps the entire enterprise of the list should be revised such that donors are on a priority list, self-destructive persons are on a second, and non-donors can be placed on some tertiary list. Radcliffe Richards contends that because the list is so long, non-donors would probably never get organs; however regardless of the practical benefits to adopting such a policy, one should adopt the moral stance that villains unwilling to save the lives of others at no cost to themselves are less deserving of organs than smokers willing to risk their own lives. The hypocrisy alone in taking an organ while being unwilling to give one is staggering, but the sheer disregard for life that is shown when one freely and knowingly refuses to donate organs after their death is appalling.

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